Anticoagulant vs Antiplatelet Therapy in Recurrent Ischemic Stroke Risk

Study authors compared the safety and efficacy of oral anticoagulants vs antiplatelets in patients with stroke and supracardiac atherosclerosis.

No significant differences were seen between anticoagulant and antiplatelet therapy in their risk of recurrent ischemic stroke in patients with stroke and supracardiac atherosclerosis; anticoagulant therapy, however, may increase the risk for major bleeding more than antiplatelet drugs, according to a systematic review and meta-analysis published in Neurology.

The meta-analysis compared the efficacy and safety of oral anticoagulants vs antiplatelets in patients with stroke and supracardiac atherosclerosis. Study authors from the United Kingdom and Europe performed a systematic review, focusing on randomized trials that compared anticoagulant and antiplatelet treatment in such patients. Studies included in the review reported outcomes, including recurrent ischemic stroke, major ischemic event or death, major bleeding, and intracranial bleeding.

In total, 10 trials with 6068 patients with stroke/transient ischemic attack (TIA) and supracardiac atherosclerosis were included in in the analysis. In the pooled cohort, a total of 3053 patients were assigned to receive anticoagulants and 3015 patients were randomly assigned to receive antiplatelets. Non-vitamin K oral anticoagulant was the primary treatment in 34.6% (n=1044) of patients in the anticoagulant group. The total estimated patient-years was 13,350, with estimated mean follow-up of 2.2 years.

The rates of recurrent ischemic stroke were found to be 2.94 vs 3.30 per 100 patient-years in patients assigned to receive anticoagulant vs antiplatelet therapy, respectively (relative risk [RR], 0.91; 95% CI, 0.70-1.18; I2=26%). No difference was observed between patients assigned to receive anticoagulants and antiplatelets regarding the rates of major ischemic events or death (4.39 vs 4.32 per 100 patient-years, respectively; RR, 1.03; 95% CI, 0.79-1.35; I2=54.5%). Higher rates of major bleeding were observed in the anticoagulant vs antiplatelet group (2.88 vs 0.82 per 100 patient-years, respectively; RR, 3.21; 95% CI, 1.96-5.24; I2=46%).

Overall, there were no significant differences between either of the treatments, with regard to efficacy outcomes or death.

Limitations of this meta-analysis were the inclusion of trials with varying criteria for patient selection and the lack of uniformity with trial follow-up periods. In addition, results may have been affected because of the premature termination of the studies used. 

Study authors concluded that their findings “do not support the use of currently available oral anticoagulants as monotherapy in patients with stroke/TIA and supracardiac atherosclerosis.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Sagris D, Georgiopoulos G, Leventis I, et al. Antithrombotic treatment in patients with stroke and supracardiac atherosclerosis. Neurology. Published online July 6, 2020. doi:10.1212/WNL.0000000000009823.